The nurse plans care to prevent a dangerous thermal environment for an older adult client who lives in a northern climate of the United States. Which client assessment data does the nurse recognize that can contribute to the risk of hypothermia? (Select all that apply.)
Has a history of alcohol abuse
Bathes three to four times a week
Has a history of diabetes mellitus
Becomes diaphoretic on warm days
is prescribed antidepressant
Has a history of a cerebrovascular accident CVA
Correct Answer : A,C,D,F
A. Has a history of alcohol abuse
Explanation: Alcohol can contribute to hypothermia as it causes vasodilation, leading to heat loss. It can impair the body's ability to regulate temperature.
B. Bathes three to four times a week
Explanation: While personal hygiene is important, the frequency of bathing alone may not be a direct risk factor for hypothermia. The overall environmental temperature and the individual's ability to regulate their body temperature are more critical considerations.
C. Has a history of diabetes mellitus
Explanation: Diabetes mellitus can increase the risk of hypothermia as it may affect circulation and peripheral nerve function. Impaired sensation and reduced blood flow can contribute to difficulty in maintaining body temperature.
D. Becomes diaphoretic on warm days
Explanation: Excessive sweating (diaphoresis) can contribute to the risk of hypothermia, as it leads to moisture loss from the skin, making it more challenging for the body to maintain a stable temperature.
E. Is prescribed antidepressant
Explanation: While certain medications, including some antidepressants, can affect thermoregulation, the prescription of an antidepressant alone does not necessarily indicate an increased risk of hypothermia. It is essential to consider the specific medication and its potential side effects.
F. Has a history of a cerebrovascular accident (CVA)
Explanation: Individuals with a history of a cerebrovascular accident may have impaired thermoregulation due to damage to the central nervous system. This can increase susceptibility to temperature extremes.
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Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Use absorbent incontinent pads.
Explanation: While absorbent incontinent pads are useful for managing incontinence, they do not directly contribute to preventing hypothermia. Maintaining warmth through appropriate clothing and insulation is more relevant to hypothermia prevention.
B. Eat high-protein meals.
Explanation: Consuming high-protein meals is important for maintaining energy and body heat. Protein metabolism produces heat as a byproduct, contributing to overall warmth.
C. Layer clothing and bedclothes.
Explanation: Layering helps trap warmth close to the body, providing insulation. This is an effective strategy to prevent heat loss and maintain body temperature.
D. Use a head covering.
Explanation: A significant amount of heat is lost through the head. Wearing a head covering, such as a hat or a cap, helps to minimize heat loss and maintain body temperature.
E. Use your comfort level to set the thermostat.
Explanation: Relying solely on personal comfort to set the thermostat may not provide adequate protection against hypothermia. It is important to keep indoor temperatures at a level that ensures warmth and minimizes the risk of cold exposure, especially for elderly individuals who may be more susceptible to temperature extremes.
Correct Answer is ["B","D"]
Explanation
B. Provide nutritious food according to the residents' expressed food preferences.
Explanation: Offering nutritious food based on residents' preferences can enhance their satisfaction with meals, making them more likely to eat and maintain adequate nutritional intake. Taking individual preferences into account helps create a more person-centered approach to nutrition.
D. Distribute "med-pass" nutritional supplements.
Explanation: Nutritional supplements may be beneficial for residents who have difficulty meeting their nutritional needs through regular meals. "Med-pass" supplements can be distributed with medications or as a separate supplement to enhance calorie and nutrient intake, especially for those with specific dietary requirements.
The other options are not recommended:
A. Develop a seating chart for the main dining room based on the unit to facilitate a more organized and efficient meal delivery.
Explanation: While organization and efficiency are important, creating a seating chart based on the unit might not directly address the nutritional status of residents. Instead, focus should be on providing appetizing, nutritious meals and accommodating residents' preferences.
C. Replace the fluorescent lighting with candles at every table to create a cozy, restaurant-like atmosphere.
Explanation: While creating a pleasant dining environment is important, replacing fluorescent lighting with candles may not be practical or safe in a healthcare setting. Moreover, the emphasis should be on the nutritional content of the meals rather than the ambiance.
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